Another Day in Triage

Tema, Ghana - Another day in triage...

The heat in the outpatient department is oppressive and sweat rolls off my back. Sluggish children and their mothers crowd the benches waiting their turn in the “queue” to see the doctor. Most are here for fevers and body aches, most likely malaria, Beatrice, the pediatric triage nurse tells us. In the United States the word “lethargic” is reserved for our critically ill patients. As I look down the benches, I see lethargic children, with sunken eyes and fontanelles. It once again is a sobering sight.

Beatrice and I have been talking all morning about the need for standardized triage protocols at Tema General Hospital. “Sister, come and look,” as Beatrice motions me to a mother delicately holding her small child wrapped in a sheet. The 4-day-old boy’s axillary temperature is 40.3 degrees Celsius; this is roughly 104.5 degrees Fahrenheit. I recognize this situation as a true emergency and question Beatrice regarding the neonatal and maternal history. “I do not know,” she says as she places the child’s chart in the front of the queue. I think to myself, it is good she recognizes this as a high risk situation and places the child at the front of the line, but in our practice, this patient needs immediate attention; he should not wait.

It is a difficult balance as an outsider trying to mentor nurses while taking into account the vast deficit of resources that we have come to depend upon. In no way do we want to discount their standard of care but we also want to ensure patients get necessary and timely attention. I quietly suggest to Beatrice that it might be best if we send the infant back to the “baby ward” and alert a physician as to the patient’s condition immediately. As we walk toward the ward, I can appreciate the stress the nurses of TGH face. They are working with a high volume of acutely ill patients with few resources. As part of the Project HOPE team, I look forward to facilitating realistic goals based on solid practices for their triage system.

Thanks for reading-Elise Chamberlain

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Changes and Challenges in Ghana

As the days progress, we continue our needs assessment of the emergency services and continue to evaluate skill sets and standardized procedures of the medical and nursing staff. We are amazed at the ingenuity, energy and dedication of the staff. They seem to do so much with so little, and so efficiently. We are identifying many similarities in our practices as well some major differences in training, standards and procedures.

The hospital lacks some very basic necessities. There is one EKG machine for the entire facility. Worse yet, is the fact that it is available less than 12 hours per day. There are no readily available airway adjuncts in most areas. Basic cardiac monitoring is nonexistent. Oxygen is a precious commodity. X-ray equipment lacks repairs for years. Trolleys (stretchers) are few and far between. Wheelchairs are craftily designed from plastic chairs.

We and those that will follow us from Project HOPE are committed to helping Tema General strengthen its weaknesses and move forward. There are certainly many stumbling blocks along the way, including lack of resources, fear of change, cultural differences, and motivational factors at all levels. We feel that this is a worthy and necessary challenge and will forge ahead one day at a time, helping and providing support as we step forward.

Thanks for reading-Marley Gevanthor and Elise Chamberlain

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Volunteers Experience Controlled Chaos

Tema, Ghana -As well seasoned triage nurses in large, high volume hospitals in Washington State and California, Project HOPE volunteers, Elise and Marley walked in to the Out Patient Department today feeling confident and prepared to start their day working side by side with their host nation counterparts. It was stifling hot. The background noise was near deafening and certainly distracting. A mass of humanity awaited care.

It was agreed that Elise would work with and mentor Beatrice in the Pediatric Department. Marley would work in the adult section with Mary, another experienced senior nurse. Patients and families were in queues at registration, medical records, the vital sign stations, the interview areas and in every available chair and bench in the consultation area. Patients arrive by walk-in, private vehicle and ambulance. Many have been referred from other facilities and clinics. Our nursing hosts are masters of organization, multitasking and directing. There is a constant bombardment of questions, interruptions, and distractions of every conceivable nature.

Elise had barely been oriented when an infant she was assessing began to seize. The child’s skin was burning. In fact, the axillary temperature was 39.7 Centigrade, a significant fever. Elise instructed the mother and nurse while demonstrating the proper technique to protect and maintain the baby’s airway. She then calmly escorted the group to the acute care area for immediate evaluation and treatment. By 1400(2pm), 93 children had been triaged by Elise and Beatrice.

Our day concluded with an elderly patient being rolled in on a trolley by her sons and daughter. “Our mother is in a coma” they stated simply. Marley immediately got up to assess the patient. The patient was unresponsive. The patient’s skin was cold. The patient was not breathing. While the patient was being moved to the acute care area for a glucose check, Marley gently suggested that perhaps the physician should be summoned while she repositioned the airway and tried to find the pulse. Although our patient most likely had died prior to arrival, her treatment might have been much more aggressive in the United States.

One of Project HOPE’s goals on this mission is to help our fellow healthcare providers optimize their limited resources and to provide mentoring and support to improve care and outcomes in these very challenging conditions.

Thanks for reading-Marley Gevanthor and Elise Chamberlain

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Need for Pre-hospital and Emergency Medical Protocols

It was only 9:30 a.m. as we walked into the Accident and Emergency Center located on the far end of Tema General Hospital (TGH) campus, but the air was thick with humidity. Seven of the eleven beds were already filled with patients that had come in over the previous days and additional patients lined the wooden benches waiting to be seen.

One of the patients, Joseph, a 35-year-old male who suffered an open fracture and dislocation of the left ankle, lay in the corner staring out the window, with a small black bible in his hand. When we went to talk to him, he greeted us warmly and explained that a metal bar had swung out and hit his leg while he worked three days ago. He had been taken to TGH where he received initial treatment including splinting and pain management. But, with no orthopedic surgeon on staff at TGH, Joseph was now awaiting transfer to the 37th Precinct Trauma Hospital in Accra, where he would receive the necessary definitive management that his injury required.

Unfortunately, Joseph's story is not unique. In a country where OSHA laws do not exist to protect workers, occupational injuries are a daily hazard in this port town. Health insurance is not offered through most employers in the region, so the patients themselves are burdened with the cost of their medical care including transfer to a higher level of care. As Dr. Charles Annan, the head of the Emergency and Accident Center at TGH explained, one of the area’s vital needs is appropriate pre-hospital protocols and proper trauma facility designation. Joseph's story highlights one of the many facets of pre-hospital and emergency medical protocols that the Project HOPE team is evaluating during our two week assessment of TGH.

Thanks for reading - Elise Chamberlain and Marley Gevanthor

Even With Minimal Resources, Emergency Preparation Possible

During our stay at Tema General Hospital (TGH) we have been afforded the opportunity to meet dozens of clinical employees. Time and again we have been impressed with the skill sets and forward thinking of these staff members given their limited resources.

One of these visionaries is Dr. Sylvia Deganus, head of the OB unit at TGH. We were fortunate enough to meet her as she passed through the hospital to pick up her mail, as she is on vacation for two weeks. While on vacation she has traveled to rural communities throughout the country to perform workshops for midwives on the importance of preparation for OB emergencies. Dr. Deganus teaches these skilled practitioners to prepare for emergencies by creating “emergency packs.” As Dr. Deganus noted “time is crucial” and “readiness during an emergency” is of the utmost importance.

Dr. Deganus has put her plan into action at TGH. In a country where the maternal mortality rate is 500 deaths to 100,000 live births and a hospital where 8,000 deliveries occur annually, she recognized the importance of swift and prepared action during maternal emergencies. Dr. Deganus was the driving force behind pre-made “emergency packs” in the maternity unit at TGH. Currently, three types of packs have been made; eclampsia, post-partum hemorrhage and ante-partum hemorrhage. These lunch-box sized, clear plastic boxes are filled with gloves, an IV catheter, tourniquet, bag of normal saline, and medications specific to the condition. Centrally located in the department the outside of each box is labeled with the contents.


As Julianne the lead OB nurse, explained she personally checks the boxes each morning to make sure all of the supplies are present. Written protocols for management of the various conditions and the responsibilities of each team member line the walls of the OB unit at TGH.

Even though evaluating maternal services was not the primary goal of this mission, by being acquainted with the different units at TGH we have found ideal practices in one unit that can be modeled throughout the facility. It is this type of emergency preparedness that Project HOPE hopes one day will be the standard throughout TGH.

Thanks for reading - Elise Chamberlain and Marley Gevanthor

A Sobering Day

Our day started on a somber note. As we approached the hospital for our first day of observation and integration into the staff of Tema General Hospital (TGH), an ambulance passed us and pulled up in front of the receiving area of the outpatient department. Since one of our focuses of this mission is to evaluate disaster response and emergency preparedness within the hospital, we stopped and introduced ourselves to the emergency technician that was cleaning and restocking the ambulance.

We had an interesting, informative discussion comparing our two countries’ disaster response and multi-casualty incident command system. Although Ghana is many years behind the U.S. in training and use of sophisticated equipment, they are striving to meet our standards of technology and education. This was a collaborative exchange with a meld of local pre-hospital providers, and our Project HOPE/Navy team.

The patient that was transported to TGH was a 10-day-old baby transferred from another facility. The baby was born prematurely at 32 weeks gestation. The EMTs escorted us to the consultation area where we observed the treatment and care of the baby. The parents waited quietly and patiently on a hard wooden bench outside the area. The baby was tiny, jaundiced, and fighting for life. The physician and nurses were quiet, solemn and calm in their approach. The baby succumbed after a few hours.

It was a sobering sight. Life is hard and cruel here in Ghana. Death often comes early and is not unexpected. Resources are limited. Yet, the people are strong and resilient and our mission could not be more clear. Our role here is to help build emergency room capacity at the facility, to make a real difference and assist in bettering these kinds of outcomes.

Thanks for reading-Marley and Elise

Volunteers Get Acquainted With Tema General Hospital in Ghana

As we drove through the gates of Tema General Hospital (TGH) we were amazed with the vast campus before us. Tema, is located approximately 30km from the capital city of Accra. TGH is a 200 bed hospital that serves a catchment area of 400,000 residents. The campus spreads over 10 acres and includes numerous buildings that house both inpatient and outpatient services.

Our first day was spent introducing our team of three Project HOPE volunteers and Lieutenant Kazmer Meszaros of the U.S. Navy, to the staff of TGH. We were welcomed with open arms into the hospital by Ms. Magdalene Ayettey, the director of nursing services, Ms. Patience Mamattah, the hospital administrator, and Dr. Charity Sarpong, the medical superintendent.

As we toured the facility we were overwhelmed with the sheer number of patients waiting to see one of the various providers. TGH sees over 500 adults in their outpatient department daily, as well as over 70 children in their outpatient pediatric department. Compounding these numbers was the amazing sight of over 150 newborns and their mothers waiting to see the midwives for their 2 week well baby check. The mothers were striking in their traditional white and black dresses, which we were told symbolizes their joy and thanks for a healthy delivery. The babies looked content nursing and amazingly not a cry was heard.

Tomorrow we look forward to meeting our emergency department counterparts at TGH and beginning our assessment of TGH’s emergency response capabilities, mass casualty operations, and health care provider skill sets.

Thanks for reading--Elise Chamberlain and Marley Gevanthor

Project HOPE Volunteers Now in Ghana

While volunteers continue work in Haiti, three more Project HOPE volunteers began a health education mission on the other side of the world in Tema, Ghana. Three emergency room specialists are volunteering at Tema General Hospital from March 13 -27. The team is focusing on emergency care and education and is providing coaching, teaching and mentoring to local emergency room care providers. Training will include disaster management, mass casualty operations, health care provider skill set evaluations and emergency room protocols.

The HOPE volunteer team in Ghana is supporting the United States Navy Africa Partnership Station 2010 program.

Meet the Project HOPE volunteers in Ghana

Robert Andrews, M.D., from Alabama Veteran's Health Care System in Montgomery, Alabama, is an emergency room physician with 28 years of experience. He is a first-time volunteer for Project HOPE.



Elise Chamberlain from St. Francis Hospital, Federal Way, Washington, is a public health and emergency room nurse. Last summer, she served as a nurse educator for Project HOPE onboard the USNS Comfort.


Marley Gevanthor, a nurse with 28 years of experience from San Francisco General Hospital in San Francisco, California is a five-time HOPE volunteer. She has volunteered for HOPE all over the world including Belize, Guatemala and Panama onboard the USNS Comfort, Papua New Guinea and Micronesia onboard the USNS Mercy and Liberia and Ghana onboard the USS Swift.

Check back for updates on Robert, Elise and Marley as they continue their work in Ghana.